Twi 3 Borough of Twickenham ANNUAL REPORT OF THE Medical Officer of Health 1935 GEORGE H. DUPONT, M.D., D.P.H., Medical Officer of Health and School Medical Officer. Twickenham: Printed by Walker & Co. (Printers), Ltd., Heath Road. Borough of Twickenham. Public Health Department, Municipal Offices, Twickenham. June, 1936. To the Mayor, Aldermen and Councillors of the Borough of Twickenham. Ladies and Gentlemen, I have the honour to submit my Report on the health and sanitary conditions of the Borough during the year 1935, and on the measures taken to safeguard and improve the health of the inhabitants. The Registrar General estimated that the population of the town had reached 46,710 in June, 1935. It is probable that Twickenham will have become a town of 50,000 inhabitants by the time that this report is published. The erection of large blocks of residential flats has continued simultaneously with the building of many separate houses, while the number and character of the shops which have been built, or the building of which is contemplated in the near future, indicates that Twickenham has come to be recognised as the most important Centre in this part of the Thames Valley. The remarkably low figures of the general death rate, the death rate of infants under one year of age and the incidence of infectious disease, are indications that the year under review was a remarkably healthy one. The transfer of the hospital treatment of cases of infectious disease to the Richmond and South Middlesex Joint Hospital Board took place in June, and in consequence Twickenham no longer has its own separate hospital for infectious disease. A record of the work carried out in connection with Housing, Sanitation, Maternity and Child Welfare, the control of infectious disease, the supervision of foods and the many other aspects of the work of caring for the health of the public will be found in the report which follows. I am, Ladies and Gentlemen, Your obedient servant, Geroage .h. Dieponth. Medical Officer of Health. 3 SUMMARY OF CONTENTS. Page. Section A.—General and Vital Statistics 3 Section B.—General Provision of Health Services 6 Section C.—Sanitary Circumstances of the Area 11 Section D.—Housing 13 Section E.—Inspection and Supervision of Food 15 Section F.—Prevalence of and Control over Infectious Disease 15 SECTION A. GENERAL STATISTICS. Area of district in acres (exclusive of portion covered by water, including 20 acres added under revision of boundaries 2,435 Population at Census, 1931 39.9S0 Population, estimated by Registrar General, to mid 1935 46,710 Number of separate dwellings, mid 1935 13,719 Rateable value, December, 1935 £436,677 Sum represented by a penny rate, gross £1,940 Rainfall during year, 1935 25.37 inches SOCIAL CONDITIONS. While there is no tendency to greater industrialisation of the borough, the increase in the erection of new dwellings has been notable. The building of houses and of blocks of self contained flats has continued and appears likely to be checked only when the amount of available open space has been occupied and when it has become uneconomical to demolish older property in order to erect new in its place. In the last annual report, the suggestion was made that flats to house the weekly wage earner might follow the building of similar dwellings for those who were able to pay a higher rent. To a comparatively small extent this development has commenced and appears likely to extend in the future. VITAL STATISTICS. Population. The population estimated by the Registrar General to the middle of the year 1935, was 46,710. As this figure is almost the same as that at which I had arrived independently some months previously, it may be accepted as approximately the actual figure. This would indicate an increase in the population of 3,233 during the year. As the natural increase of the population, i.e., the excess of births over deaths was only 126, the balance of 3,107 consisted of persons who had moved to Twickenham from other places. Births. Total births registered 716 Number of live births 693 Number of still births 23 Increase in total births compared with 1934 60 Birth rate (live births) per 1,000 of the population 14.8 The birth rate (live births) was exactly the same as that for 140 towns in England and Wales, with populations of comparable size. The sex and legitimancy of the live births was:- Male. Female. Total. Legitimate 325 335 660 Illegitimate 19 14 33 344 349 693 The birth rate has remained almost stationary for the past 4 years, during which it has averaged 14.5 per 1,000 of the population. The number of still births registered was 23, of which 16 were male. No illegitimate still birth was registered. The still birth rate was 32 per 1,000 of the total births and 0.49 per 1,000 of the estimated population of the town. The proportion of illegitimate births was one in every 21 of the total births registered. 4 Deaths. Nett number of deaths 467 Decrease compared with year, 1934 24 Death rate per 1,000 of the estimated population 9.9 Decrease compared with year, 1934 1.6 The death rate of 9.9 per 1,000 of the estimated population was the lowest since the year 1930, which in its turn was the lowest on record. It may be noted that the death rate for 140 towns with population of comparable size was 11.2 per 1,000, and that for England and Wales generally was 11.7 per 1,000. CAUSES OF DEATH AT ALL AGES. Year 1935. Registrar General's figures. Causes of Death. Males. Females. Total. All causes 237 230 467 1. Typhoid and Paratyphoid Fevers - - - 2. Measles - - - 3. Scarlet Fever - 1 1 4. Whooping Cough — — — 5. Diphtheria 1 2 3 6. Influenza 3 5 8 7. Encephalitis Lethargica — — — 8. Cerebro-spinal Fever 1 — 1 9. Tuberculosis of respiratory system 17 10 27 10. Other tubercular diseases 2 4 6 11. Syphilis 1 1 2 12. General paralysis of the insane, tabes dorsalis 3 1 4 13. Cancer, malignant disease 40 37 77 14. Diabetes 4 4 8 15. Cerebral haemorrhage, etc. 0 9 IS 16. Heart disease 52 67 110 17. Aneurysm 1 — 1 18. Other circulatory diseases 7 13 20 19. Bronchitis 5 7 12 20. Pneumonia (all forms) 13 9 22 21. Other respiratory diseases 2 2 4 2 Peptic ulcer 1 — 1 23. Diarrhoea,, etc. (under 2 years) 1 2 3 24. Appendicitis 2 2 4 25. Cirrhosis of liver 2 — 2 26. Other diseases of the liver, etc. 2 1 3 27. Other digestive diseases 5 6 11 28. Acute and chronic nephritis 6 5 11 29. Puerperal sepsis — 2 2 30. Other puerperal causes — 2 2 31. Congenital debility, premature birth, malformations, etc. 13 5 18 32. Senility 3 6 9 33. Suicide 3 9 5 34. Other violence 12 8 20 35. Other defined diseases 26 17 43 36. Causes ill-defined or unknown - - - Compared with the preceding year there was a decline in the deaths from infectious disease, and in deaths as the result of suicide and other forms of violence. The deaths from cancer and diseases of the heart and circulation were practically the same as for the year 1934. The cancer death rate per 1,000 of the population was 1.64. The number of deaths from pulmonary tuberculosis was 27, compared with 16 during 1934. Deaths from Infectious Diseases. Disease 1934 1935 Number Rate per 1000 of population. Number Rate per 1000 of population. Measles 8 0.8 — - Whooping cough — - — — Scarlet fever 3 0.06 1 0.02 Diphtheria 3 0.06 3 0.0G Enteric fever 1 0.02 - — Influenza 3 0.06 8 0.17 Tuberculosis (pul.) 16 0.30 27 0.57 5 Puerperal Death's. Four women died from causes associated with pregnancy and childbirth, two of these deaths being ascribed to puerperal sepsis. The maternal death rate was therefore 5.5 per 1,000 total births for the year. Three of these deaths occurred in institutions outside Twickenham, and consequently information as to the occurrence was not received until the death was transferred by the Registrar General a considerable time after the death had taken place. The cases of death were set out as follows:— (1) Puerperal septicaemia. (2) Septic miscarriage. (3) Heart failure after delivery. (4) Acute heart failure early in pregnancy. It was possible to make enquiries in reference to cases (1) and (3) only, and in both all reasonable care appears to have been exercised throughout the pregnancy and labour. The maternal deaths during the past five years have resulted from the following causes :— 1931 1932 1933 1934 1935 From Sepsis — 1 — 2 2 From other causes 1 3 — — 2 Infant Deaths. Nett deaths of infants under 1 year of age 29 Infant death rate per 1,000 live births 41.8 Infant death rate per 1,000 legitimate births 39.3 Infant death rate per 1,000 illegitimate births 90.9 Deaths from diarrhoea (under 2 years) per 1,000 live births 3 Death rate from diarrhoea (under 2 years) per 1,000 live births 4.3 The infant death rate for 140 towns with populations of comparable size was 55. That for Twickenham was 41.8. The death rate of infants during their first year of life per 1,000 live births was, with the exception of the years 1930 and 1931, the lowest recorded infant death rate. Table of death rates per thousand live births of infants in Twickenham during the past 25 years. Year Rate Year Rate Year Rate 1911 111.7 1919 66.3 1927 55.4 1912 68.7 1920 58.2 1928 52.0 1913 79.7 1921 84.7 1929 61.1 1914 80.5 1922 70.2 1930 40.3 1915 100.2 1923 72.2 1931 39.2 1916 85.6 1924 54.6 1932 51.4 1917 82.2 1925 70.1 1933 52.0 1918 113.9 1926 49.0 1934 65.2 1935 41.8 The number of infants who died before the end of the first month of life was 17, giving a neonatal death rate of 24.5 per thousand live births. The neonatal death rate for the past Ave years has been :— Year lst week 2nd week 3rd week 4 th week Rate 1931 8 1 — 3 19.6 1932 8 2 — 1 18.1 1933 15 1 2 1 32.1 1934 14 2 — 2 28.6 1935 14 1 2 — 24.5 6 The following table shows the deaths of infants under 5 years of age which occurred during 1935. Causes of death of children under 5 years of age, 1935. CAUSES OF DEATH. 1 week 1-2 weeks 2-3 weeks 3-4 weeks Total under one month 1-3 months 3-6 months 6-9 months 9-12 months Total under one year 1-2 years 2-3 years 3-4 years 4-5 years Total under five years Measles ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 Whooping Cough ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 Erysipelas ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tuberculosis ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... 2 Bronchitis ... ... ... ... ... 1 ... 1 ... ... ... ... ... ... 2 Pneumonia ... ... ... ... ... ... 1 ... ... 1 3 1 1 ... 6 Enteritis & Gastritis ... ... ... ... ... 2 l ... ... 3 ... ... ... ... 3 Syphilis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Atelectasis 1 ... ... ... 1 ... ... ... ... 1 ... ... ... ... 1 Accident or injury at birth 1 ... ... ... 1 ... ... ... ... 1 ... ... ... ... 1 Congenital malformations 1 ... ... ... 1 1 ... ... 1 3 ... ... ... ... 3 Premature birth 7 1 1 ... 9 1 ... ... ... 10 ... ... ... ... 10 Debility 1 ... ... ... 1 ... ... ... ... 1 ... ... ... ... 1 Atrophy and Marasmus ... ... ... ... ... 2 ... ... ... 2 ... ... ... ... 2 Other diseases 2 ... ... ... 2 1 ... 1 ... 4 1 1 2 ... 8 Violence 1 ... 1 ... 2 ... ... ... ... 2 ... ... ... ... 2 Inattention at birth ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Total 14 1 2 ... 17 8 2 2 1 30 5 3 4 1 43 The total number of deaths under one year of age in this table differs slightly from those in the table of the Registrar General, as the period to which they refer is not identical with that from which this figure was taken. Public Mortuary. During the year 44 bodies were brought into the mortuary. Twenty-seven post-mortem examinations were made and twenty-one inquests were held. SECTION B. GENERAL PROVISION OF HEALTH SERVICES. Public Health Officers of the Local Authority. (a) Medical:— Medical Officer of Health, School Medical Officer, Medical Superintendent of Infectious Diseases Hospitals, and Medical Officer to the MaternityandChildWelfareCommittee : George H. Dupont, M.D., C.M., D.P.H. Whole time. Assistant to Medical Officer of Health and Medical Officer to the Ante-Natal Clinic : Ethel Richmond Emslie, M.D., D.P.H. Whole time. Ophthalmic Surgeon : C. J. Longwortii Blair, M.R.C.S. Part time. Dental Surgeon : G. Woolford, L.D.S., R.C.S. Part time. Aurist: R. Savage, M.B., F.R.C.S. Part time. (b) Other:— Senior Sanitary Inspector: Leonard Marsden, Cert.R.S.I., Sanitary Inspector and Inspector of Meat and Other Foods. Whole time. Sanitary Inspector: Major Vincent Sutclii-fe, Cert.R.S.I., Sanitary Inspector and Inspector of Meat and Other Foods. Whole time. Health Visitor (Principal): Beatrice Pilkington, S.R.N., Cert., Central Midwives Board and Health Visitors' Certificate, R.S.I. Whole time. Health Visitor: Ethel Dunkley, S.R.N., Cert., Central Midwives Board and Health Visitors' Certificate, R.S.I. Whole time. Health Visitor: Matilda G. Heath, S.R.N., Cert., Central Midwives Board and Health Visitors' Certificate, R.S.I. Whole time. School Nurse: Laura Manning, S.R.N. Whole time. Clerks: Walter Brearley, Cert., Sanitary Inspector, R.S.I., Violet Williams, Barbara Heslett and George Goram. Whole time. Mortuary Attendant: W. Parsons. 7 Nursing in the Home. General. The Nurses of the Twickenham Nursing Association continued the home nursing of persons who were suffering from those diseases for the nursing of which the Council is able to make provision. Three whole-time nurses are now employed. The Council contribute £100 to the Association for these services. From the monthly returns received, the following visits were recorded as paid to patients who came under the Council's scheme:— Visits paid to patients under 5 years, 1010 ; over 5 years, 553. Total visits paid, 1563. Nursing of Infectious Cases. Cases of Pneumonia, Whooping Cough and Ophthalmia Neonatorum, were nursed in their own homes. Provision for home nursing of cases of puerperal fever was not required during the year. Midwives. The number of Midwives who declared their intention of practising in the district during the year was 21. Applications were received for assistance in providing the services of a midwife from 6 necessitious women who desired to be confined in their own homes, and all were granted. Home Helps. The services of a home help were granted in 3 cases. The home helps assist in the domestic duties of the homes during the time that the mother is incapacitated on account of her confinement or some complication of pregnancy. No wholetime home help has been appointed, but the patient is allowed to select her own help, provided the person selected is not a relative, and the selection is approved by the Medical Officer. The arrangements for the provision of midwives and home helps have functioned satisfactorily and the assistance granted in this way has been appreciated. Although a large number of women enter lying-in hospitals and nursing homes for their confinement, it is a matter of very considerable difficulty for a mother to do this when a family of young children have to be left at home especially when, as so frequently happens, a suitable relative cannot be found who is able to undertake this very important duty. It is in cases such as this that the assistance given by providing a midwife and a home help is so valuable, as the mother can remain at home and exercise supervision even if not able to participate actively in the household duties for the time being. Nursing Homes. The Middlesex County Council are the supervising authority for maternity homes in the Borough. The number of nursing homes in Twickenham at the end of the year was 9. LEGISLATION IN FORCE. The adoptive Acts and Bye-Laws which are in force in the Borough, and which have been set out in detail in previous reports, remained unaltered. HOSPITALS. For Smallpox. The provision of hospital treatment for smallpox is made by the Middlesex County Council under the " Prevention and Treatment of Smallpox Regulations, 1928." For Other Infectious Diseases. The Twickenham Hospital for infectious diseases passed over to the control of the Joint Hospital Board on April 1st, 1935. The transfer of the hospital closed a chapter in the history of public health administration in Twickenham which opened many years ago. It has not been possible to fix the date on which Twickenham first established an infectious diseases hospital. A small hospital at the Mereway was erected by Twickenham Local Board in 1883. This building still exists although it has not been used as a hospital for a long time. Before the Mereway Hospital was erected a cottage hospital was leased and appeared to be in use at the date of the formation of the Local Board. I remember, many years ago, a small derelict cottage on the Mereway allotments being indicated to me as the old fever hospital. If this was correct it was indeed a " cottage " hospital in the true sense of the word. By action with other Authorities it has now become possible to have a modern hospital of sufficient size to provide medical and other services of a character which would be impossible in the case of a small institution serving one district only. The enlarged Mogden Hospital will ultimately be the finest infectious diseases hospital in Middlesex. 8 The Joint Board are now responsible for the treatment of cases of infectious disease arising in Hampton, Hampton Wick, Heston-Isleworth, Richmond, Teddington and Twickenham, an area of which the population is approximately 220,000 persons. The Mogden Isolation Hospital in Isleworth, formerly used by Richmond and HestonIsleworth jointly, is to be enlarged so as to accommodate ultimately all the cases which will be received. The Hospital at Nelson Road, Twickenham, is being retained by the Joint Board for the reception of patients until the extensions to the Mogden Hospital are ready, after which time, presumably, it will be closed. The small hospital at Hampton is no longer being used. In view of the combined action now taken voluntarily by no less than six neighbouring authorities to establish a joint hospital, it is interesting to recall that in 1909 the Twickenham Urban District Council declined to accede to a request from a neighbouring authority that occasional cases of infectious disease arising in that authority's district should be received in the Twickenham hospital. It is probable that the annual contribution which Twickenham has to make towards the cost of the new hospital when the extensions are completed will be greater than that which has been paid in the past, but it must be remembered that if it had been decided that Twickenham should continue to maintain an infectious diseases hospital for its exclusive use, it would have been necessary to double the size of the small Twickenham hospital at Whitton and to have rebuilt the nurses home and administration block. Not only would this have involved a large capital outlay, but the maintenance charges would have been increased in proportion. Admissions. As the hospital was transferred to the Joint Board at the end of March the figures given below refer only to patients admitted to hospital from this Borough. The number of these was as follows :— Scarlet fever 39 Diphtheria 16 Typhoid fever 1 Other diseases 7 63 Other Hospitals. The only general hospital in the Borough is St. John's Hospital, of which the management is by a voluntary Committee and there is no resident medical staff. The number of beds is 34. The other hospitals largely used by Twickenham residents are the West Middlesex County Hospital, Isleworth, and the Royal Hospital, Richmond. Extensive use is also made of the general and special hospitals in London. Maternity Homes. There is no municipal maternity home in the Borough. Maternity cases are received at almost all the private nursing homes, and admission to the maternity Wards at the West Middlesex County Hospital is much sought after. CLINICS AND WELFARE CENTRES. Following is a list of clinics and treatment centres within the borough :— Name. Address. Days of Attendance. By whom provided. Maternity and York house Tuesday, Wednesday, Twickenham Council Child Welfare Thursday, at 2 p.m. Clinic Infant Welfare Murray Park hall, Mondays, 2.30 p.m. ditto Centre and Whitton Branch School Clinic Ante-natal Clinic York house Second and last Friday ditto in each month School Clinic, in- York house Daily Twickenham Educacluding minor tion Committee ailments, dental and ophthalmic clinics Tuberculosis Dis- 1 Staines Road Wednesdays, 10 a.m. Middlesex County pensary Council, Diphtheria Immun- York House Saturdays, 9.30 a.m., Twickenham Council ization Clinic 9 Ambulances. Two motor' ambulances are maintained by the Corporation for attendance in the case of casualties and for the removal of other patients to nursing homes and hospitals or between private addresses. As the calls, especially to casualties, continued to be numerous, the need for a second ambulance became imperative and it was decided in February to purchase a 14 h.p. Talbot ambulance at a cost of £696. This vehicle is constructed and fitted with all modern improvements and is entirely satisfactory. In addition to the ordinary equipment, a Novox resuscitation apparatus for the restoration of asphyxiated persons has been fitted. After delivery of the Talbot, opportunity was taken to thoroughly overhaul the older Austin ambulance, and the importance of having a reserve vehicle has been demonstrated on many occasions. More than once during the year it has been necessary to turn out both vehicles simultaneously in the case of severe casualties. Following is a table of the use of the ambulances during the year 1935. Total calls Casualtycalls Patients carried Mileage Calls during 1934 1st quarter 131 64 127 548.4 115 2nd quarter 123 60 116 591.2 123 3rd quarter 80 50 79 416.9 125 4th quarter 127 63 137 914.7 127 461 237 459 2471.2 490 The casulaty calls amounted to 51.41 per cent. of the total calls during the year. The ambulances are maintained and staffed by the Fire Brigade, and the condition in which they are kept and the services rendered on all occasions have been entirely satisfactory. Reciprocal: arrangements for the use of the ambulance service made with the adjoining authorities have continued to be satisfactory, no difficulty or delay having been experienced. Laboratory Facilities. The bacteriological examination of specimens has for many years been carried out carefully and well at a laboratory in London. On many occasions however, owing to the distance and to postal delays, some inconvenience has arisen. It was decided therefore, to entrust this work to Dr. D. S. Murray who is the Hon. Pathologist to the Royal Hospital, Richmond. The new arrangement has proved satisfactory. MATERNITY. The total number of births which were notified as occurring in the borough during the year was 668, of which 21 were still births. S births were not notified. Of the notifications of births, 471 were made by midwives and 197 by doctors or parents. Midwives were present therefore in 70.5 per cent. of the births, but it is possible that a medical practitioner was also present at some of the cases notified by midwives. Care of the expectant mother. The Ante-Natal Clinic was held every fortnight during the year. The total attendances of expectant mothers numbered 381 of which 123 were first attendances. Calculated on the births which occurred in Twickenham, 19.3 per cent. of all women confined in Twickenham attended the Ante-Natal Centre. This however, does not include the women who received pre-natal observation elsewhere than at the Clinic. A large number of the confinements which took place at nursing homes in Twickenham, were those of women who resided in other towns, and it may be assumed that these had received the necessary pre-natal care in most instances. It may also be assumed that all the cases attended at their own homes by medical practitioners or midwives, received at any rate some pre-natal care and the same remark applies to those confined in West Middlesex Hospital Maternity Block (103), and in special hospitals in London (29). Under the scheme by which assisted dental treatment is provided, 40 expectant mothers received the necessary treatment, the total attendances.being 85. In accordance with requests from the Public Assistance Authority, enquiries were made into the home conditions of 20 expectant mothers living in Twickenham who had applied for admission to the maternity block of the West Middlesex Hospital, and reports were furnished to that authority. Under the scheme for the supply of milk to necessitous expectant mothers, milk was supplied in 4 cases. 10 Birth Control. Facilities are available by which women, in whom pregnancy is to be avoided for mcdical reasons, may obtain the necessary advice at a Birth Control Clinic in London. Care of mothers during Confinement. The Corporation have not established a Maternity Home and no formal arrangement has been made with any hospital for the reception of complicated or difficult cases of labour. Although the services of a consultant are available to medical practitioners in cases of complicated or difficult labour, no request for these services was received during the year. Midwives or Home Helps were provided in approved cases to attend necessitous women who desired to be confined at home, as follows:— Midwives 6 Home Helps 3 Subsequent to Confinement. The services of a consultant are available for case of puerperal pyrexia when medical practitioners desire a special opinion and the patient is not in a position to afford an adequate fee. No application was received for these services during the year. Milk was supplied to 23 necessitous nursing mothers. Dental treatment was provided in approved cases, for nursing mothers as follows:— Nursing mothers 20 Total attendances 51 Dentures supplied 8 Child Welfare. Home Visiting. The Health Visitors called at the homes when a birth occurred in 626 cases out of the live births notified. Visits of enquiry were also made in the case of 11 still births and of 11 infant deaths. The visits paid to homes by the Health Visitors during the year included the following:— To expectant mothers 217 To children under one year of age 3043 To children between the ages of 1 and 5 years 4303 Winter School for Health Visitors. During each winter one of the Health Visitors attends a study course. By this means they are enabled not only to refresh their knowledge of the work but to be kept in touch with developments in Maternity and Child Welfare work. Infant Welfare Centres. The infant consultations were held on four afternoons weekly throughout the year ; that at Murray Park Hall, Whitton, being held on Monday and those at York House on Tuesda)', Wednesday and Thursday afternoons. The total attendances numbered 7,S19. In this figure only those attending for consultation or weighing are counted. New cases. Centre No. 1. York House. Centre No. 2. Whitton. Totals. Under 1 year 250 07 347 1 to 5 years G7 48 115 Mothers 8 3 11 Total Attendances:— Under 1 year 3552 1531 5083 1 to 5 years 1827 891 2718 Mothers 15 3 18 Total attendances at all the Centres 7819 The Centres are primarily for observation and advice as to the care and nutrition of children. Medical and surgical treatment are not carried out. When these arc found necessary, as is frequently the case, the parent is referred to a private doctor or to a hospital. During the year treatment was advised for 100 children and was obtained by 93. 11 Dental treatment for children under 5 years was given to 18 children. All the cases were extractions of carious teeth, which were carried out under "gas" anaesthesia. The treatment of middle ear suppuration which is so common a disease in infancy or early childhood was carried out at the school minor ailment clinic, cases being referred to the Consulting Aurist when necessary. The chief difficulty experienced in the treatment of this condition arises from the fact that the treatment must be thoroughly carried out and it is not easy for mothers of young children to attend frequently and regularly. Under the arrangement made for this treatment, 4 infants attended during the year. One child who suffered from crippling deformity of the legs in consequence of severe rickets was admitted to the Royal National Orthopaedic Hospital for treatment, at the expense of the Committee. Infant Life Protection. The Health Visitors are appointed as infant life protection visitors under the Children Act, 1908. The details as to registration during 1935 were as follows:— Number of foster children on register at beginning of year 62 Number removed from register 44 Number registered for first time during year 39 Number on register at end of 1935 57 Deaths of foster children Nil SECTION C. SANITARY CIRCUMSTANCES OF THE AREA. Almost every house in the Borough derives its water supply from that of the Metropolitan Water Board. A few cesspools still exist on the Heathfield Farm Estate and Eel Pie Island, but water closet accommodation is general throughout the district which is sewered on the separate system. The sewage disposal works of the Corporation continued to dispose of all the sewage of the borough, as the new West Middlesex sewage scheme had not commenced to function at the end of the year. The collection of house refuse is carried out under the direction of the Borough Surveyor and Engineer, from whose reports it is found that during the year, 10,870 tons of refuse were disposed of in the destructor, a limited quantity being dealt with by tipping. Sanitary Inspection. The details of this work, which include domestic sanitation, housing inspection, supervision of food supplies (including milk, meat and other foods), the investigation and abatement of nuisances, the sanitation of workshops and factories, the supervision of offensive trades, the investigation of and disinfection after the occurrence of cases of infectious disease and the storage of petrol and carbide of calcium, will be found under the appropriate headings. The figures give some indication of the attention needed to secure effective supervision in this very important branch of public health work. The total number of inspections and re-inspections carried out during the year was 7,378. The visits paid in respect of each branch of the duties of the inspectors are set out under each heading. In consequence of these visits, notices were served on owners or occupiers as follows:— Informal notices (intimations) served 291 Informal notices complied 282 Statutory notices served 6 Statutory notices complied 3 Domestic Sanitation. Included under this heading will be found the visits paid by the Sanitary Inspectors, under the Housing Regulations, to premises where nuisances were suspected and visits for the purpose of enquiry and disinfection after the occurrence of infectious disease. Visits to premises after complaint 463 Visits after the occurrence of infectious disease 162 Visits under Housing Regulations 55 Total visits and inspections 7,378 12 The following works were carried out in consequence of the above visits:— Drains tested 20 Drains unstopped and repaired 70 Waste pipes disconnected or repaired 18 Soil pipes provided or repaired 2 Inspection chambers inserted 1 Complete drainage reconstructions 4 Water supply cisterns repaired 8 Draw taps from main provided 24 Gutters repaired 62 Roofs repaired 147 W.c. apartments repaired or re-built 39 W.c's repaired 66 Dustbins provided 80 Damp walls remedied 159 Ventilation provided 29 Yards paved or repaired 38 Rooms stripped and cleansed 159 Offensive accumulations removed 12 Other works carried out 611 Schools. The sanitary conveniences, water supply and lavatories were inspected quarterly throughout the year and found to be satisfactory. Offensive Trades. Three applications to establish the trade of fish fryer in the district were received during the year. In one instance the application was not proceeded with, one application was granted, and one was refused. The following offensive trades which have been established were kept under regular ■ supervision:— Fish fryers 9 Fat melters 2 Rag and bone dealers. 1 The number of visits paid by the sanitary inspectors to premises where offensive trades were carried on was 85. Petroleum Acts. Fifty-six licences were issued to 53 persons to keep petroleum spirit. Of these 17 were authorised to keep petrol in cans. Six licences were granted to 4 persons to keep carbide of calcium. The number of visits paid by the Inspectors in connection with these premises was 199. FACTORIES AND WORKSHOPS. Number of factories in the district 67 Number of workshops 94 Number of workplaces 2 In accordance with the requirements of the Factory and Workshops Act, 1901, a statement of inspections is submitted, together with the defects found, and the result of action taken. INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES, Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. Number of Inspections Written Notices Prosecutions (1) (2) (3) (4) Factories (including Factory Laundries) 126 3 - Workshops (including Workshop Laundries) 180 5 - Workplaces (other than Outworkers' premises) 2 — — Total 308 8 — 13 DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. (1) (2) (3) (4) (5) *Nuisances under the Public Health Acts:— Want of cleanliness 2 1 — - Want of ventilation — — — - Overcrowding — — — — Want of drainage of floors — — — - Other nuisances 1 1 — - Sanitary accommodation— insufficient 2 1 — - unsuitable or defective 2 2 — - not separate for sexes - - - — Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouse (s. 101) — — — — Other offences 4 4 -- - (Excluding offences relating to out-work and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factory and Workshops Transfer of Powers) Order, 1921) Total 11 9 — - ♦Including those specified in sections 2, 3, 7 and 8 of the Factory and Workshop Act, 1901, as remediable under the Public Health Acts. Shop Acts. The Sanitary Inspectors are not concerned with the provisions of these acts as to hours of employment, closing days and arrangements for meals, but undertake the supervision of the arrangements for hand washing and the sanitary accommodation in shops. SECTION D. HOUSING. The increase in the number of houses in the borough will be appreciated when it is noted that not less than 1,416 separate dwellings came into rating for the first time during the year. The passing into law of the Housing Act, 1935, marked one of the most important stages towards the improvement of the conditions under which a large portion of population has hitherto been compelled to live. Its most striking provisions are those which define overcrowding and under certain conditions make it a punishable offence on the part of the person who causes the overcrowding or the owner who permits it. The standard of overcrowding as laid down by the Act is admittedly a low one, but at any rate it is clearly defined and may be considered to be satisfactory as a beginning. Under this Act, the obligation was laid upon the local authority to cause a survey to be made to ascertain the number of dwellings which were overcrowded on the basis laid down in the Act. Arrangements to carry out this survey were made at the end of the year, four temporary investigators being specially engaged for the purpose. It was estimated that approximately 5,500 dwellings would have to be investigated, occupied by a number of families considerably in excess of this figure. The survey was commenced at the end of December under the direction of the Medical Officer of Health. The ordinary inspection of the district to ascertain the houses which, although unfit for habitation, were capable of being rendered fit and those dwellings which were unfit and incapable of being rendered fit at a reasonable expense, was continued actively throughout the year. Considerable attention was paid to the condition of basement dwellings. In consequence of the demand for houses during the past 16 years, the basements of the older type of large house have been occupied as separate dwellings by those who were unable to pay the rent asked cither for a whole house or the upper portion of a house. In consequence, the less well off families, most frequently with children, have been compelled to live entirely in basements which, when the houses were built, were only intended for kitchens, sculleries and larders and possibly a servants' day room. Such basement flats make an entirely unsuitable dwelling, especially for children. They are, as a rule, sunless and the air invariably seems to possess a stagnant character which is almost intolerable to those who are not used to it. It may be said without fear of contradiction that a dilapidated cottage, all of which is above ground, is preferable as a dwelling to even the best of basement fiats in the old houses. 14 It is only fair to most owners to say that they recognise the unsuitability of many of these flats as a dwelling and several have voluntarily undertaken extensive work in order to satisfy the necessary conditions as to lighting, ventilation and freedom from dampness. Others have not proved to be so amendable. It is an expensive matter to carry out the necessary works, but where these have been carried out in a thoroughly satisfactory way, theowners do not appear to have had any difficulty in letting at a satisfactory rent. In 3 instances basement flats were represented to the local authority as being unfit for human habitation. In addition to the action taken in respect of underground rooms, representations were made in respect of 16 other houses that they were unfit for human habitation and could not be rendered so fit at a reasonable expense. In 13 cases demolition orders were made, and as no appeal was lodged against these decisions, the orders became operative. In 2 instances the Authority accepted an undertaking from the owners not to permit the use of the dwellings for human habitation until the works necessary were carried out. In one case a Closing Order was made in respect of part of a house. Following are the details of houses inspected during the year and action taken in connection therewith:— 1. Inspection of Dwelling-houses during the Year— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 294 (b) Number of inspections made for the purpose (excluding re-inspections) 344 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 25 (b) Number of inspections made for the purpose (excluding re-inspections) 75 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 18 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 276 2. Remedy of defects during the Year without Service of formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 260 3. Action under Statutory Powers during the Year:— A.—Proceedings under sections 17, 18 and 23 of the Housing Acts, 1930: (1) Number of dwelling-houses in respect of which notices were served requiring repairs Nil (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners Nil (b) By local authority in default of owners Nil B.—Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 4 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 3 (b) By local authority in default of owners Nil C.—Proceedings under sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Demolition Orders were made 13 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 5 D.—Proceedings under section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made 1 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil 15 SECTION E. INSPECTION AND SUPERVISION OF FOOD. Milk. Milk is now delivered almost entirely in glass bottles, but in 28 instances milk is sold in sealed cartons. No bacteriological examinations of milk samples were made. At the end of the year the register was as follows:— Cowkeepers 2 (5 cows kept) Dairymen 16 Purveyors of milk 38 Milk under special designations was sold by dairymen as follows:— Certified milk 10 Grade"A" milk 1 Grade "A" tuberculin tested 11 Pasteurised 14 Licensed to bottle Grade "A" T.T. milk 1 Licensed to pasteurise milk 1 Meat. Although some registered slaughter-houses remain in the Borough, most of them have not been used for a very considerable period, and slaughtering locally may be said to have ceascd. No seizure of unsound or diseased meat was made, but 37 lbs. of unsound meat was surrendered voluntarily. There are 4S butchers' shops in the Borough, which were kept under close supervision, 350 visits being paid for this purpose by the Sanitary Inspectors. Other Foods. Regular supervision of other shops from which foodstuffs were sold was also exercised, the following visits being paid for this purpose:—restaurants and eating house kitchens and grocers' shops, 330 visits; greengrocers' shops, 236 visits; fish shops, 103 visits. The following unsound fruit was surrendered voluntarily during the year:—31 tins cherries. SECTION F. PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DISEASES The number of cases of notifiable infectious disease which occurred during 1935 is set out in the following table. Cases in which the diagnosis was not confirmed on observation subsequent to notification are not included. Month Diphtheria Scarlet Fever Puerperal Fever Puerperal Pyrexia Pneumonia Primary Pneumonia Influenzal Ophthalmia Neonatorum Erysipelas Typhoid Fever Ceiebro Spinal Fever Malaria Dysentery January 25 1 — — 1 — — 1 1 February 2 4 — — 6 1 - 1 — — March 3 4 — — 1 4 — 1 — - - - April 1 1 — — 2 1 — — — - - - May 1 5 1 — — 1 1 — — — — - June 3 4 1 — — — 1 1 — — - - July 1 6 — — 1 — — 2 — - - - August 2 4 — — 1 — — 1 - - - - September — 7 — — — — - — 1 - - - October 3 1 — — 1 — — 1 — - - - November 1 1 — - 1 1 - - - - - December — 6 — — — — — 1 — — — — totals 42 44 2 — 14 7 3 9 1 — - 1 16 Infectious Disease, 1935. Ages at notification. Disease Total 1 Notifications Under 1 1-2 2-3 3-4 4-5 5-10 10-15 15-20 20-25 25-35 35 45 45-65 65, etc. Admitted to hospital Deaths Diphtheria 42 — — 2 6 3 17 7 3 1 1 2 — — 36 3 Scarlet Fever 44 — — — 1 3 25 4 2 2 4 1 2 — 42 - Puerperal Fever . ! 2 — — — — — — — — — 2 - — — — Puerperal Pyrexia - — — — — - — — — — - - - - - - Pneumonia:— Primary 14 — — — — — 3 — — 3 4 — 4 — — - Influenzal 7 - - - - - - - - - 1 3 3 — — — Ophthalmia Neonatorum 3 3 - - - - - - - - - - - - - - Erysipelas 9 — 1 — — — — 2 1 1 — — 3 1 — — Acute Polio-myelitis - - - - - - - - - - - - - - - - Malaria - — — — — - - - - - — — — — - - Dysentery 1 - - - - - 1 - - - - - - - - - Typhoid 1 - - - - - - - - 1 - - - — 1 — The year 1935 was remarkable for a low incidence of infectious disease of all kinds, the total number of notifications being 123, less than half that of the preceding year and lower than that for any year since 1924. Scarlet Fever. The type of disease met with was mild, and no deaths resulted. Although cases occurred during every month of the year, seven notifications during September was the highest figure for any month of the year, and there was no localised outbreak. Diphtheria. The somewhat heavy incidence of this disease during 1934 continued in January 1935, twenty-five cases occurring during that month. From that time onward only occasional cases arose, and during 28 weeks of the year no notification of this disease was received. The type of the cases arising in the early part of the year was somewhat severe, three deaths occurring, but from that time the disease assumed a milder character. Other Diseases. One case only of typhoid fever was notified and measles was absent from the district throughout the year. Notifications of Erysipelas, which were unduly numerous during 1934, fell to 9 during the year under review. Immunization against Infectious Disease. The end of a completed year of active work in the protection of children against Diphtheria, offers a suitable opportunity for a review of the position in Twickenham. Although all the children in one large boarding school (The Police Orphanage) had been tested and immunised against this disease, this form of protection had not been made available to the public generally until a Clinic for this particular purpose was established in December, 1934. The time was auspicious, because it coincided with a somewhat extensive prevalence of Diphtheria which has continued for some months. A circular explaining immunization and pointing out its advantages, was sent to the home of every school child as far as possible, to every other home where there were children under school age. The response to the school circulars was so great as to be embarrassing. The one session weekly, with which a commencement was made, was soon found to be entirely inadequate, and three sessions weekly were found necessary from January until August. Until the end of October, two sessions weekly were held and it has since been found possible to reduce the session 17 to one weekly. The attendances at each session were high, on one occasion they reached 153, and the average for a considerable portion of the year was 91, but they have now reached manageable proportions. The whole of this work was undertaken without the engagement of specialist or additional staff. Dr. Emslie, whose experience of this work had been considerable before coming to Twickenham, undertook the major portion of the duties at the Clinic, and I desire to acknowledge specially the assistance rendered by her in this respect. All children over 7 years of age were first tested by the Schick test to find out if they were liable to contract diphtheria, and if found susceptible received as a rule three injections of Toxoid Anti-toxin Mixture (T.A.M.) at intervals of a fortnight. As children under 7 years are almost invariably found to be liable to contract diphtheria, the preliminary Schick test was dispensed with. It was anticipated that the injection of T.A.M. might produce somewhat severe reaction in the case of older children, and for a time Toxoid Anti-toxin Floccules (T.A.F.) were used for these. It was found however, that reaction of any severity with T.A.M. was rare and the use of T.A.F. was discontinued almost completely. In all cases an appointment for a subsequent Schick test was given, at intervals of from two to four months after the last prophylactic injection. If on this subsequent test the child appeared to be protected, a certificate to that effect was given. In no case was a certificate given without a negative result of a final Schick test. The figures given below give some indication of the extent of the work, which will be realised more readily when it is remembered that for each child immunized, and certified, at least four, and in most cases five attendances were made. Although the number of children dealt with has been so considerable, it has not been large enough to be altogether satisfactory. Approximately 32 per cent. of the children under 7 years of age in Twickenham are protected from Diphtheria as the result of the injections given or are naturally immune, while of those between 7 and 15 years of age, 28 per cent. are protected. It is estimated that before it can be said the children of any district are safe from diphtheria, 60 per cent. should be immunised. It will be realised therefore that continued activity on the part of the Authority and continued interest on the part of the parents are still essential. It is regrettable that the number of children under 5 years who are brought for immunization is not greater, as it is among these that the danger from Diphtheria is greatest. It will be necessary therefore to consider the means if any, by which parents can be induced to bring their young children for protection. The number of persons who attended the Clinic for testing or inoculation or both, with their ages at date of first attendance, were as follows:— Ages. 1 2 3 4 5 6 7 8 9 10 11 12 15 20 25 to to to X Total 15 20 25 79 108 116 105 184 216 162 176 197 146 180 287 18 — 14 1988 The total attendances were 8,761 Following is a summary of the work done :— First Schick Test before inoculation— Number Susceptible Immune Failed to attend. 1117 806 308 3 N umber receiving first completed course of injections 1502 Second Schick test of those who had completed first course of injections:— Number Protected, Susceptible Failed to attend. 1317 1230 65 22 All those found to be incompletely protected after the second Schick test were re-inoculated arid all those re-tested were found to be immune. Two did not appear for re-test. 18 Table of notifications of Infectious Disease during the past ten years. 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 Anthrax - 1 - - - - - - - - Small-pox - 1 - - - - - - - - Scarlet Fever 25 49 71 124 173 102 96 9 1 106 44 Diphtheria 60 88 117 93 136 64 27 29 121 42 Dysentery — — - 28 — - - - - 1 Enteric Fever 4 3 3 3 2 1 1 - - 1 Puerperal Fever 2 — 3 6 2 2 1 1 4 2 „ Pyrexia 3 6 2 8 2 6 4 2 1 Ophthalmia Neonatorum 6 3 1 3 1 6 5 3 3 Pneumonia:— Primary 19 24 15 22 6 19 14 17 14 14 Influenzal 6 10 5 17 4 6 5 6 8 7 Erysipelas 13 10 17 9 11 7 12 8 23 9 Malaria — 1 — - - - 2 1 1 - Encephalitis I.ethargica 1 - - 1 - - - - - - Acute Polio Encephalitis - - - - - - - - - - Poliomyelitis — — — — - - - 1 - - Cerebro-spinal Fever — — - - - - - - - - Tuberculosis:— Pulmonary 36 42 40 44 49 44 51 27 45 43 Non-pulmonary 13 16 11 13 14 2 9 11 3 8 Tuberculosis. Following is a table of the notifications of new cases of tuberculosis received during the year, with the ages at the time of notification and a table of the deaths which occurred as the result of tuberculosis, with the ages at which death occurred. Age Periods New Cases Deaths Pulmonary NonPulmonary Pulmonary NonPulmonary M. F. M. F. M. F. M. F. 0 - - - - - - - - ] — — 1 - - - 1 1 5 - - 1 - - - - 1 10 - — 1 1 - - 1 - 15 4 3 1 - 2 1 - - 20 3 2 — - 2 1 - - 25 4 12 1 1 4 5 - - 35 8 1 — — 4 1 - - 45 2 3 — - 4 1 - - 55 1 — — 1 1 1 - 2 G5 and upwards - - - - - - — - Totals 22 21 5 3 17 10 2 4 The treatment of cases of tuberculosis is carried out by Officers of the Middlesex County Council, but all cases residing in the Borough were visited at regular intervals by the Health Visitors of the Corporation.